Provider Demographics
NPI:1841261302
Name:PHILLIPS ROCHE A CRI CLINIC PHARMACY INC
Entity type:Organization
Organization Name:PHILLIPS ROCHE A CRI CLINIC PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACARDY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-847-5949
Mailing Address - Street 1:PO BOX 136
Mailing Address - Street 2:
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-0136
Mailing Address - Country:US
Mailing Address - Phone:800-343-3784
Mailing Address - Fax:608-847-5004
Practice Address - Street 1:402 W LAKE ST
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:WI
Practice Address - Zip Code:53934-9699
Practice Address - Country:US
Practice Address - Phone:608-339-9080
Practice Address - Fax:608-339-3023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WI8465-423336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2115259OtherPK
WI33187500Medicaid
WI33187500Medicaid